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Population-Based Healthcare: the Experience of a Regional Health System 1 2 Eugene Shum, MPH, FAMS, Chien Earn Lee, M Med (PH), FAMS

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Population-Based Healthcare: the Experience of a Regional Health System 1 2 Eugene Shum, MPH, FAMS, Chien Earn Lee, M Med (PH), FAMS Population-based Healthcare—Eugene Shum and Chien Earn Lee 564 Editorial Population-based Healthcare: The Experience of a Regional Health System 1 2 Eugene Shum, MPH, FAMS, Chien Earn Lee, M Med (PH), FAMS Introduction the competition to shift from being between individual Asian populations are experiencing a much faster rate of institutions to integrated networks. However, the limitation ageing compared to western countries.1 Western countries of the 2 cluster systems was that it included only public sector such as France and the United States took 115 years and institutions which might not have necessarily corresponded 69 years respectively for the percentage of population aged to the way patients accessed healthcare services. It was also 65 years and over to rise from 7% to 14%. In contrast, it is constrained in addressing healthcare at the population level projected that countries such as South Korea, Singapore, as some key stakeholders (e.g. general practitioners (GPs) Thailand and China would experience this increase within and voluntary welfare organisations) were not included. a much shorter time frame of 18 to 26 years. In Singapore, The Singapore healthcare system further evolved with the percentage of population aged 65 years and over is the formation of 6 regional health systems (RHS). Each projected to increase from 8.4% in 2005 to 18.7% in 2030.2 RHS was responsible for the population in a region. The Accordingly, the period that Singapore has to respond to the aim was to move from episodic to patient level care; from demands of a rapidly ageing population in terms of socio- providing healthcare services to also keeping individuals cultural changes and healthcare system is much shorter. in good health; and from interventions at individual level Singapore has a healthcare system that is ranked highly to also include systems level interventions focussing on internationally in terms of performance and effi ciency. population health. This necessitated close partnerships It was ranked sixth for health system performance in the and collaboration beyond the public health institutions to World Health Report 20003 and fi rst in the Bloomberg also include voluntary welfare organisations and private second annual ranking of countries with the most effi cient healthcare providers in particular primary care providers. healthcare.4 A key contributing factor is Singapore’s continued investment and development of the healthcare Eastern Health Alliance and Changi General Hospital system. In response to the increasing demand for healthcare, the government health expenditure has increased by 46% The Eastern Health Alliance, the RHS for the population from $4.1 billion in 2011 to $6 billion in 2013.5 in eastern Singapore, was offi cially launched on 18 November 2011. Amongst the 6 RHS, the Eastern Health With a rapidly ageing population, there will be more frail Alliance is unique in its formal partnership with a range of older persons with chronic diseases living in the community. healthcare organisations each with a specifi c focus along There will be a need to support these older persons in the healthcare continuum. These foundation partners are terms of healthcare services and social support to live Changi General Hospital (CGH), Health Promotion Board, independently in the community. Similarly, there will be a St Andrew’s Community Hospital, SingHealth Polyclinics need to engage them in advance care planning and support and the Salvation Army Peacehaven Nursing Home. Each of them in end-of-life care. It is imperative to shift from an these organisations is independent as only Changi General acute hospital centric model of care to a population-based Hospital is owned by the Eastern Health Alliance. They approach where the healthcare services that a person needs have joined together with the shared purpose of providing across different settings are well-planned and coordinated. seamless integrated care in the east. This in turn provided for the close partnership between the management and Development of Regional Health Systems operations teams of the various organisations. In 2000, the public healthcare institutions in Singapore The Eastern Health Alliance takes a population health were organised into 2 healthcare clusters—SingHealth and approach in the development and delivery of health services National Healthcare Group. The aim was to allow better in the eastern region of Singapore which has a population of integration of public health institutions such as polyclinics, more than one million residents. At the RHS HQ level, the acute hospitals and national specialty centres. This allowed Eastern Health Alliance has a convenor and coordinating 1Corporate Development, Eastern Health Alliance, Singapore 2Executive Offi ce, Changi General Hospital, Singapore Address for Correspondence: Dr Eugene Shum, Eastern Health Alliance, 5 Tampines Central 1, Tampines Plaza #08-01/05, Singapore 529541. Email: [email protected] December 2014, Vol. 43 No. 12 565 Population-based Healthcare—Eugene Shum and Chien Earn Lee role. This is analogous to being the conductor of an orchestra. to improve functional status of patients (and also reduce use It analyses and understands the profi le and healthcare needs of resources and saving costs).8 Thirdly, with the increasing of specifi c populations and local communities; it identifi es capability of primary care providers, outpatient care at the partners, resources and assets in the community; and it hospital should focus on patients with complex medical coordinates programme delivery, link partners and where conditions requiring multidisciplinary, multispecialty care. necessary develop new services. This allows residents in Fourthly, CGH also serves as a resource for the Eastern the east to have access to a comprehensive range of services Health Alliance and its partners. For example as part of the across the healthcare continuum that is coordinated by the GPFirst programme, there is a 24/7 hotline for GPs on the RHS HQ in collaboration with its partners. programme to discuss cases with the emergency department Community-led initiatives such as the Naturally Occurring consultant if necessary. Retirement Communities6 and the Village model7 have an It is critical for the hospital and RHS to work in tandem important role in facilitating ageing-in-place. Learning and collaboratively to meet the needs of the population— from these initiatives, the Neighbours for Active Living complementing and leveraging on each other’s strengths to programme was set up by the Eastern Health Alliance in ensure that individual and systems/population perspectives partnership with the South East Community Development are addressed. Council (SE CDC) in July 2013. This programme supports patients with high medical and social needs who are living Conclusion in the east. It has a team of social work professionals and para-professionals who assess and ensure that clients receive The setting up of the RHS has allowed for a population- the support services that they require. The programme is based approach to healthcare. It has led to a healthcare system unique in several aspects. Firstly, the community care team that is more responsive to the needs of our population. It is embedded in the community. Each team is sited full time takes into account the life cycle stages and needs of the in a local community where they support clients living in the patient and their caregiver as an important factor. For area and work closely with the organisations sited there. An example, the needs of a single young adult may be different added advantage of this is that they also serve as “sensors” from a married person with young children even if they in the community to detect and help those who may not have the same medical condition. Finally, it has allowed step forward to seek assistance. Secondly, there is close us more options in considering the patient experience and participation by the community. The SE CDC organises the to address what matters to the patient even as we manage Friend-a-Senior programme to engage and train residents issues such as compliance with treatment. in the community to be volunteer befrienders. With the strong support from the community, clients can continue to be monitored and follow-up longitudinally by the RHS for as long as they require it. Thirdly, the programme bridges both the health and social needs of the client. Since the REFERENCES launch of the programme, more than 1000 clients have 1. Kinsella K, He W. An Ageing World: 2008. Washington DC: National been enrolled in the programme. Institute of Aging and U.S. Census Bureau, 2009. Within this ecosystem, the hospital is a very important 2. Committee on Ageing Issues: Report on the Ageing Population, 2006. component. It is an expensive resource but it can be a cost- 3. The World Health Report 2000, World Health Organisation, 2000. effective resource if used appropriately. CGH has defi ned its 4. Most Effi cient Health Care 2014: Countries. Bloomberg second annual role in the healthcare ecosystem to focus on 4 key thrusts. ranking of countries with the most effi cient healthcare. Available at: http:// Firstly, it is to save lives through timely intervention. media.bloomberg.com/bb/avfi le/rhpTqieX4Fuc. Accessed 3 November 2014. The hospital still remains the most appropriate place to 5. Government Health Expenditure. Singapore Health Facts, Ministry of manage patients with acute conditions such as myocardiac Health. Available at: https://www.moh.gov.sg/content/moh_web/home/ infarct, stroke and serious trauma that require complex statistics/Health_Facts_Singapore/Healthcare_Financing.html. Accessed investigations and interventions. Secondly, the hospital 3 November 2014. plays a critical role in restoring functionality by mitigating 6. Masotti PJ, Fick R, Johnson-Masotti A, MacLeod S. Healthy naturally the deconditioning effects of hospitalisation and illness. occurring retirement communities: A low-cost approach to facilitating healthy aging. Am J Public Health 2006;96:1164-70. The aim is to present patients in as good a condition as 7.
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